Canadian Interventional Radiology Association Research Articles

Society of Interventional Radiology Reporting Standards for Thoracic Central Vein Obstruction: Endorsed by the American Society of Diagnostic and Interventional Nephrology (ASDIN), British Society of Interventional Radiology (BSIR), Canadian Interventional Radiology Association (CIRA), Heart Rhythm Society (HRS), Indian Society of Vascular and Interventional Radiology (ISVIR), Vascular Access Society of the Americas (VASA), and Vascular Access Society of Britain and Ireland

Society of Interventional Radiology Reporting Standards for Thoracic Central Vein Obstruction: Endorsed by the American Society of Diagnostic and Interventional Nephrology (ASDIN), British Society of Interventional Radiology (BSIR), Canadian Interventional Radiology Association (CIRA), Heart Rhythm Society (HRS), Indian Society of Vascular and Interventional Radiology (ISVIR), Vascular Access Society of the Americas (VASA), and Vascular Access Society of Britain and Ireland

Interventional Radiology in Canada: Current Challenges and Future Directions.

We aim to define the practice of interventional radiology (IR) in Canada, barriers that have been faced by interventional radiologists, and ways in which the Canadian Interventional Radiology Association (CIRA) have attempted to address these issues. IR has faced significant challenges in the Canadian setting. Recognizing the need to address these challenges, leaders in the field of IR in Canada founded the CIRA to serve as our national voice and lobby group.

Clinical IR in Canada: The Evolution of a Revolution

PurposeTo investigate the current status and evolution of both the interventional radiologist’s role as a clinician and the practice of interventional radiology (IR) over the past decade in Canada. Materials and MethodsIn 2015, an online survey was e-mailed to 210 interventional radiologists, including all Canadian active members of the Canadian Interventional Radiology Association (CIRA) and nonmembers who attended CIRA’s annual meeting. Comparisons were made between interventional radiologists in academic versus community practice. The results of the 2015 survey were compared with CIRA’s national surveys from 2005 and 2010. ResultsA total of 102 interventional radiologists responded (response rate 49%). Significantly more academic versus community interventional radiologists performed chemoembolization, transjugular intrahepatic portosystemic shunt, aortic interventions, and arteriovenous malformation embolization (P < .05). Ninety percent of respondents were involved in longitudinal patient care, which had increased by 42% compared with 2005; 46% of interventional radiologists had overnight admitting privileges, compared with 39% in 2010 and 29% in 2005. Eighty-six percent of interventional radiologists accepted direct referrals from family physicians, and 83% directly referred patients to other consultants. Sixty-three percent participated in multidisciplinary tumor board. The main challenges facing interventional radiologists included a lack of infrastructure, inadequate remuneration for IR procedures, and inadequate funding for IR equipment. Significantly more community versus academic interventional radiologists perceived work volume as an important issue facing the specialty in 2015 (60% vs 34%; P = .02). ConclusionsOver the past decade, many Canadian interventional radiologists have embraced the interventional radiologist-clinician role. However, a lack of infrastructure and funding continue to impede more widespread adoption of clinical IR practice.

Multisociety consensus quality improvement guidelines for intraarterial catheter‐directed treatment of acute ischemic stroke, from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology

In this international multispecialty document, quality benchmarks for processes of care and clinical outcomes are defined. It is intended that these benchmarks be used in a quality assurance program to assess and improve processes and outcomes in acute stroke revascularization. Members of the writing group were appointed by the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society of Cardiac Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology. The writing group reviewed the relevant literature from 1986 through February 2012 to create an evidence table summarizing processes and outcomes of care. Performance metrics and thresholds were then created by consensus. The guideline was approved by the sponsoring societies. It is intended that this guideline be fully updated in 3 years. In this international multispecialty document, quality benchmarks for processes of care and clinical outcomes are defined. These include process measures of time to imaging, arterial puncture, and revascularization and measures of clinical outcome up to 90 days. Quality improvement guidelines are provided for endovascular acute ischemic stroke revascularization procedures.

Clinical Practice Guidelines for Endovascular Abdominal Aortic Aneurysm Repair: Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association

From the Department of Radiology, Division of Vascular Imaging and Intervention (T.G.W., S.P.K., K.Y., S.W.), Massachusetts General Hospital, Boston, Massachusetts; Department of Medical Imaging (S.K.), Scarborough General Hospital, Toronto, Ontario, Canada; Department of Interventional Radiology (P.D.), West Allis Memorial Hospital, Milwaukee, Wisconsin; Department of Radiology, Division of Interventional Radiology (B.J.D.), University of Maryland Medical Center, Baltimore, Maryland; Department of Radiology (S.C.R.), University of California San Diego Medical Center, San Diego, California; and Department of Radiology (J.F.C.), Geisinger Health System, Danville, Pennsylvania. Received May 4, 2010; final revision received May 24, 2010; accepted July 11, 2010. Address corre-

Guidelines for Peripheral and Visceral Vascular Embolization Training: Joint Writing Groups of the Standards of Practice Committees for the Society of Interventional Radiology (SIR), Cardiovascular and Interventional Radiological Society of Europe (CIRSE), and Canadian Interventional Radiology Association (CIRA)

Guidelines for Peripheral and Visceral Vascular Embolization Training: Joint Writing Groups of the Standards of Practice Committees for the Society of Interventional Radiology (SIR), Cardiovascular and Interventional Radiological Society of Europe (CIRSE), and Canadian Interventional Radiology Association (CIRA)

Multi-society Consensus Quality Improvement Guidelines for the Treatment of Lower-extremity Superficial Venous Insufficiency with Endovenous Thermal Ablation from the Society of Interventional Radiology, Cardiovascular Interventional Radiological Society of Europe, American College of Phlebology, and Canadian Interventional Radiology Association

Neil M. Khilnani, MD, Clement J. Grassi, MD, Sanjoy Kundu, MD, FRCPC, Horacio R. D’Agostino, MD, Arshad Ahmed Khan, MD, J. Kevin McGraw, MD, Donald L. Miller, MD, Steven F. Millward, MD, Robert B. Osnis, MD, Darren Postoak, MD, Cindy Kaiser Saiter, NP, Marc S. Schwartzberg, MD, Timothy L. Swan, MD, Suresh Vedantham, MD, Bret N. Wiechmann, MD, Laura Crocetti, MD, John F. Cardella, MD, and Robert J. Min, MD, for the Cardiovascular Interventional Radiological Society of Europe, American College of Phlebology, and Society of Interventional Radiology Standards of Practice Committees

Multi-disciplinary Quality Improvement Guidelines for the Treatment of Lower Extremity Superficial Venous Insufficiency with Ambulatory Phlebectomy from the Society of Interventional Radiology, Cardiovascular Interventional Radiological Society of Europe, American College of Phlebology and Canadian Interventional Radiology Association

Sanjoy Kundu, MD, FRCPC, Clement J. Grassi, MD, Neil M. Khilnani, MD, Fabrizia Fanelli, MD, Sanjeeva P. Kalva, MD, Arshad Ahmed Khan, MD, J. Kevin McGraw, MD, Manuel Maynar, MD, Steven F. Millward, MD, Charles A. Owens, MD, Leann S. Stokes, MD, Michael J. Wallace, MD, Darryl A. Zuckerman, MD, John F. Cardella, MD, and Robert J. Min, MD, for the Cardiovascular Interventional Radiological Society of Europe, American College of Phlebology, and Society of Interventional Radiology Standards of Practice Committees

Interventional Radiology Deserves Formal Recognition as a Distinct Medical Subspecialty: A Statement from the Canadian Interventional Radiology Association

IN 2003, the Canadian Interventional Radiology Association (CIRA), the national body that represents interventional radiology (IR) in Canada, applied to the Royal College of Physicians and Surgeons of Canada (RCPSC) for subspecialty recognition under the broader specialty of diagnostic radiology. The application was widely supported by stakeholder specialty societies and involved a twostep process. Step 1 was approved on March 22, 2004. Step 2 was rejected by the Committee of Specialties on May 4, 2006, on the grounds that IR did not meet the criteria of a subspecialty. The RCPSC also stated that the entry routes into IR were too restrictive, the extra training beyond that of diagnostic radiology did not meet the expectations for a subspecialty, and the advancement of an area focused on ‘additional technical competence’ did

Shortcomings in Interventional Radiology in Canada and What is Needed for Change

To describe the current and future financial needs of interventional radiology (IR) in Canada. The Millennium Research Group, an independent market research firm, was commissioned by the Canadian Interventional Radiology Association to create a report examining the current status and outlook of interventional radiology in Canada. This article presents some of the key findings. The incidence of some of the major diseases relevant to interventional radiologists, as well as smoking and obesity, is predicted to increase over the next few years, leading to an expected increased demand for IR procedures. This will in turn further exacerbate a current shortage. To become a G7 leader in terms of number of IR procedures performed per population, Canada would need to increase its number of interventional radiologists by an additional 241% from 2005 levels. Canada must spend an additional Can$221.3 million annually to support IR in Canada, which would lead to estimated savings of at least Can$180.3 million in direct health care costs and Can$92.3 million in societal costs annually, as well as at least 402 lives and 98,010 hospital-bed days saved. Canada, and more specifically hospital administrators, politicians, and medical policy-makers, must substantially increase funding, awareness, and support of interventional radiology in Canada to ensure first-world medical care to the Canadian population. By not doing so, dollars, lives, complications, and waiting times are being and will continue to be forfeited.

Limitations Influencing Interventional Radiology in Canada: Results of a National Survey by the Canadian Interventional Radiology Association (CIRA)

To describe the current state and limitations to interventional radiology (IR) in Canada through a large, national survey of Canadian interventional radiologists. An anonymous online survey was offered to members of the Canadian Interventional Radiology Association (CIRA). Only staff radiologists were invited to participate. Seventy-five (75) responses were received from a total of 247, giving a response rate of 30%. Respondents were split approximately equally between academic centers (47%) and community practice (53%), and the majority of interventional radiologists worked in hospitals with either 200-500 (49%) or 500-1,000 (39%) beds. Procedures listed by respondents as most commonly performed in their practice included PICC line insertion (83%), angiography and stenting (65%), and percutaneous biopsy (37%). Procedures listed as not currently performed but which interventional radiologists believed would benefit their patient population included radiofrequency ablation (36%), carotid stenting (34%), and aortic stenting (21%); the majority of respondents noted that a lack of support from referring services was the main reason for not performing these procedures (56%). Impediments to increasing scope and volume of practice in Canadian IR were most commonly related to room or equipment shortage (35%), radiologist shortage (33%), and a lack of funding or administrative support (28%). Interventional radiology in Canada is limited by a number of factors including funding, manpower, and referral support. A concerted effort should be undertaken by individual interventional radiologists and IR organizations to increase training capacity, funding, remuneration, and public exposure to IR in order to help advance the subspecialty.

Canada's slow adoption of new technologies adds burden to health care system

It is interesting to compare how developed countries adopt new technologies. In terms of novel minimally invasive treatments, these are often within the domain of interventional radiology. The Canadian Association of Radiologists (CAR) and the Canadian Interventional Radiology Association (CIRA)

Attitudes of and Influences on Residents in English Canadian Radiology Programs Regarding Interventional Radiology: Results of a National Survey by the Canadian Interventional Radiology Association (CIRA)

There has been a North American trend toward reduced application to the subspecialty of Interventional Radiology (IR). Out of fear of a looming manpower shortage, this survey was conducted to better understand awareness and attitudes toward IR by radiology residents-in-training. An anonymous online survey was emailed to the Diagnostic Radiology Residency Program Director/Department Chairperson of each of the 13 English medical schools in Canada, to be forwarded to each respective Radiology Residency Program's radiology residents. The survey was open for a period of 1 month. The survey consisted of 29 questions, which could be answered online using a web-based program. Responses to questions were tabulated and comments recorded. A total of 84 survey responses were received of a possible 333 (25%), including responses from each of the 13 English Programs. Responses regarding demographics, training, careers aspirations and motivations, and influences were collected. Fifty-one percent of respondents reported being either "moderately" or "very" interested in the field of IR; however, only 13% reported intention to perform an IR fellowship. A number of issues were identified as dissuading current radiology residents from pursuing IR, including income, work hours and hours of on-call, and turf issues. A number of issues were identified as factors which prevented residents with an interest in IR from applying to IR fellowships. These must be addressed to increase IR recruitment rates of radiology residents.

Function of the Günther Tulip Vena Caval Filter

As an interventional radiologist with a strong interest in vena caval filters, I read the evidence-based guidelines of the Seventh ACCP Conference with careful attention. In the second part of the publication, Antithrombotic Therapy for Venous Thromboembolic Disease, 1 Buller HR Agnelli G Hull RD et al. Antithrombotic therapy for venous thromboembolic disease: Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004; 126: 401S-428S Abstract Full Text Full Text PDF PubMed Scopus (1306) Google Scholar Dr. Buller and colleagues have made a citation error in Section 4.5, vena caval interruption for the initial treatment of pulmonary embolism. They state that the Günther Tulip filter (Cook; Bloomington, IN) appears to be “less satisfactory.” To support this they provide a reference from 1992. 2 Bull PG Mendel H Schegl A Gunther vena cava filter: objective evaluation of early results. J Vasc Interv Radiol. 1992; 3: 395-399 Abstract Full Text PDF PubMed Scopus (20) Google Scholar This reference is to the Günther Basket filter (which has been withdrawn from sale), not the Günther Tulip filter. Although the similarity of the names could cause confusion, the Günther Tulip filter is a completely different device. It functions well as both a permanent vena caval filter, and as a retrievable device. 3 Neuerburg JM Gunther RW Vorwerk D et al. Results of a multicentre study of the retrievable Tulip vena cava filter: early clinical experience. Cardiovasc Intervent Radiol. 1997; 20: 10-16 Crossref PubMed Scopus (123) Google Scholar , 4 Millward SF Oliva VL Bell SW et al. Gunther Tulip retrievable vena cava filter: results from the Registry of the Canadian Interventional Radiology Association. J Vasc Interv Radiol. 2001; 12: 1053-1058 Abstract Full Text Full Text PDF PubMed Scopus (212) Google Scholar The maximum window between implantation and retrieval is not known, but successful retrieval has been reported after implantation periods of up to 126 days. 5 Terhaar OA Lyon SM Given MF et al. Extended interval for retrieval of Gunther Tulip filters. J Vasc Interv Radiol. 2004; 15: 1257-1262 Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar On Some AnalysesCHESTVol. 128Issue 3PreviewThere are methodological errors being made in statistical analyses, resulting in flawed results. Examples are in the studies by Hiasa et al1 and Oudiz et al.2 The problem is the authors’ use of two-sample t tests, analysis of variance, or analysis of covariance to compare means, which assumes the normality and equality of unknown variances in the groups considered. The Central Limit Theorem justifies normality for mean inferences, but unknown variances need not be equal, making these methods not generally applicable to comparing means. Full-Text PDF

Günther Tulip Retrievable Vena Cava Filter: Results from the Registry of the Canadian Interventional Radiology Association

To report data collected by the Canadian Registry of the Günther Tulip Retrievable Filter (GTF). Between February 1998 and December 2000, 90 patients at eight hospitals underwent implantation of 91 GTFs. There were 45 male patients and 45 female patients, age 17-88 years, with a mean age of 49 years. Indications for filter placement were pulmonary embolism (PE) or deep vein thrombosis (DVT) with a contraindication to anticoagulation in 83 patients, prophylaxis after massive PE in one, prophylaxis for proximal free-floating thrombus in one, and prophylaxis with no DVT or PE in six patients (major trauma, n = 4; high preoperative risk, n = 2). GTF retrieval was attempted in selected patients from a right internal jugular vein approach. One GTF was inadvertently placed in the right iliac vein and could not be retrieved. There were no other major placement complications. GTF retrieval was attempted in 52 patients (53 GTFs); 52 GTFs were successfully retrieved from 51 patients. Implantation times were 2-25 days (mean, 9 d). Of these 51 patients, 37 underwent follow-up for 5-420 days (mean, 103 d) after filter retrieval. Four patients (8% of retrieved GTFs) required reinsertion of a permanent filter 17-167 days (mean, 78 d) after GTF retrieval as a result of bleeding from anticoagulation (n = 2) or because the patient required further surgery (n = 2). One other patient had recurrent DVT 230 days after retrieval; no PE or other complication was documented in the retrieval group. GTFs were not retrieved from 39 patients for various reasons. Of these 39 patients, 25 underwent follow-up 7-420 days (mean, 85 d) after filter placement. Two patients developed filter occlusion (5%); no other complications were documented. The GTF has a broad range of utility: it can be used as a permanent filter or retrieved after implantation periods of 15 days and possibly longer. However, indications for retrieval require further study, as does the maximum implantation time.